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Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group. Blood 2021; 136:2103-2117. [PMID: 32808006 DOI: 10.1182/blood.2020005221] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022] Open
Abstract
Pregnancy and postpartum are high-risk periods for different forms of thrombotic microangiopathy (TMA). However, the management of pregnancy-associated TMA remains ill defined. This report, by an international multidisciplinary working group of obstetricians, nephrologists, hematologists, intensivists, neonatologists, and complement biologists, summarizes the current knowledge of these potentially severe disorders and proposes a practical clinical approach to diagnose and manage an episode of pregnancy-associated TMA. This approach takes into account the timing of TMA in pregnancy or postpartum, coexisting symptoms, first-line laboratory workup, and probability-based assessment of possible causes of pregnancy-associated TMA. Its aims are: to rule thrombotic thrombocytopenic purpura (TTP) in or out, with urgency, using ADAMTS13 activity testing; to consider alternative disorders with features of TMA (preeclampsia/eclampsia; hemolysis elevated liver enzymes low platelets syndrome; antiphospholipid syndrome); or, ultimately, to diagnose complement-mediated atypical hemolytic uremic syndrome (aHUS; a diagnosis of exclusion). Although they are rare, diagnosing TTP and aHUS associated with pregnancy, and postpartum, is paramount as both require urgent specific treatment.
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Choi HS, Yun JW, Kim HJ, Oh D, Kim NI, Kim CS, Ma SK, Kim SW, Bae EH. Atypical hemolytic uremic syndrome after childbirth: a case report. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:79. [PMID: 33553372 PMCID: PMC7859817 DOI: 10.21037/atm-20-3789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report a case of atypical hemolytic uremic syndrome (HUS) that occurred after childbirth. A 33-year-old female was admitted to the emergency room, complaining of abdominal pain six days after giving birth to twins. The patient was diagnosed with hemoperitoneum due to hepatic hemangioma rupture and a left lateral hepatectomy was performed. Angioembolization was performed for the accompanying uterine artery bleeding. After that, her kidney function worsened after the 12th day postpartum. Microangiopathic anemia, thrombocytopenia and renal dysfunction were observed. Shiga toxin-producing Escherichia coli was negative in the stool. Plasma ADMATS 13 activity was normal. After transfer to the nephrology department with suspected atypical HUS, the patient underwent fresh frozen plasma (FFP) transfusion with three hemodialysis sessions. The patient improved without additional dialysis, but a renal biopsy was performed because of persistent proteinuria. Renal pathologic findings were compatible with thrombotic microangiopathy. A genetic test for atypical HUS revealed variants of uncertain significance in the complement factor H related (CFHR) 4 gene and the presence of CFHR3-CFHR1 copy number gain. The CFHR3-CFHR1 copy number gain found in this case is a rare causative mutation of atypical HUS. This case suggests that genetic testing of atypical HUS should include analysis of CFH-CFHR rearrangements as well as general screening for complement-associated genes.
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Affiliation(s)
- Hong Sang Choi
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jae Won Yun
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Veterans Medical Research Institute, Veterans Health Service Medical Center, Seoul, Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doyeun Oh
- Department of Internal Medicine, School of Medicine, CHA University, School of Medicine, Seongnam, Korea
| | - Nah Ihm Kim
- Department of Pathology, Chonnam National University Medical School, Gwangju, Korea
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Covella B, Alrukhaimi M, Liu ZH, Ashuntantang G, Orozco Guillen A, Cabiddu G, Li PKT, Garcia-Garcia G, Levin A. Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases. J Clin Med 2018; 7:jcm7100318. [PMID: 30275392 PMCID: PMC6210235 DOI: 10.3390/jcm7100318] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/14/2022] Open
Abstract
Pregnancy-related acute kidney injury (pAKI), preeclampsia (PE), and the hypertensive disorders of pregnancy are closely related conditions, which are, in turn, frequently linked to pre-existing and often non-diagnosed chronic kidney disease (CKD). The current literature and research mainly underline the effects of pregnancy complications on the offspring; this review strongly emphasizes the maternal health as well. These conditions not only negatively affect pregnancy outcomes, but have a relevant effect on the future health of affected mothers and their children. Therefore, dedicated diagnostic and follow-up programs are needed, for optimizing materno-foetal health and reducing the impact of pregnancy-related problems in the mothers and in the new generations. This narrative review, performed on the occasion of the 2018 World Kidney Day dedicated to women’s health, focuses on three aspects of the problem. Firstly, the risk of AKI in the hypertensive disorders of pregnancy (the risk is the highest in developing countries; however PE is the main cause of pregnancy related AKI worldwide). Secondly, the effect of AKI and the hypertensive disorders of pregnancy on the development of CKD in the mother and offspring: long-term risks are increased; the entity and the trajectories are still unknown. Thirdly, the role of CKD in the pathogenesis of AKI and the hypertensive disorders of pregnancy: CKD is a major risk factor and the most important element in the differential diagnosis; pregnancy is a precious occasion for early diagnosis of CKD. Higher awareness on the importance of AKI in pregnancy is needed to improve short and long term outcomes in mothers and children.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy.
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, 101000 Moscow, Russia.
- Nephrology, Moscow State University of Medicine and Dentistry, 101000 Moscow, Russia.
- Nephrology, Russian Medical Academy of Continuous Professional Education, 101000 Moscow, Russia.
| | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, 10100 Torino, Italy.
| | - Margarita Ibarra Hernandez
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, 44100 Guadalajara Jal, Mexico.
| | - Bianca Covella
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, P.O. Box 20170, Dubai, UAE.
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210000, China. zhihong--
| | - Gloria Ashuntantang
- Yaounde General Hospital & Faculty of Medicine and Biomedical Sciences, University of Yaounde I, P.O. Box 337, Yaounde, Cameroon.
| | | | | | - Philip Kam Tao Li
- Prince of Wales Hospital, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong.
| | - Gulliermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, 44100 Guadalajara Jal, Mexico.
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
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